Rev. Bras. Geriatr. Gerontol.

2023;26:e230012

Alzheimer’s disease: a case study involving the most prevalent

neurocognitive disorder in older people

Case Report
1 of 6

Luciane Fabricio Zanotto1 ID

Vanessa Aparecida Pivatto1 ID

Ana Paula Gonçalves Pinculini1 ID

Eliana Rezende Adami2 ID

Abstract
Objective: To analyze the clinical evolution of a patient affected by Alzheimer's disease
and discuss the repercussions of an early diagnosis. Method: Instrumental case study
of qualitative and descriptive type that was developed in three stages: 1) selection and
delimitation of the case; 2) collection of data in the field; and 3) organization and writing
of the report. This study is based on the analysis of the clinical evolution described in the
medical records of a patient diagnosed with Alzheimer's disease, treated and followed-
up by the Center for Psychosocial Care (CAPS), for a period of 10 years, in the Alto
Vale do Rio do Peixe region. Results: This study was conducted with the patient M.R.,
Keywords: Alzheimer
female, 71 years old, married, housewife, with incomplete elementary education, carrier
Dementia. Early diagnosis.
of AD and hypothyroidism, who started her follow-up at CAPS II on September 10, Drug therapy. Case Reports.
2012. Patient submitted to the Mini Mental State Examination (MMSE), with a result
of 14 points in the first test, below the cut-off point for the patient's level of education.
Later, in 2018, she scored 10 points on the MMSE, and in 2020 she scored 11, already
under medication treatment for AD: memantine 10mg 2x/day and donepezilla 5mg 1x/
day. Conclusion: Early diagnosis of AD is extremely important for appropriate treatment
to slow the progression of the disease. However, mental disorders such as depression
are barriers in the initial clinical analysis of patients and in some cases presents itself as
a prodrome for AD.

1
Universidade Alto Vale do Rio do Peixe, Departamento de graduação em Medicina. Caçador, SC, Brasil.
2
Universidade Alto Vale do Rio do Peixe, Programa de Pós-graduação em Desenvolvimento e Sociedade.
Caçador, SC, Brasil.

No external funding was received supporting this study

The authors declare no conflict in the conception of this study.

Correspondence
Luciane Fabricio Zanotto Received: January 21, 2023
lucianezanotto1@hotmail.com Approved: April 11, 2023

http://dx.doi.org/10.1590/1981-22562023026.230012.en
Alzheimer's dementia a case report
INTRODUCTION
Alzheimer´s Disease (AD) is characterized as a
neurocognitive disorder with a progressive course.
The condition first affects the hippocampus, the
region of the brain responsible for memory, and
later involves other areas of the brain. The disease
represents the leading cause of dementia in older
adults and directly impacts the autonomy and quality
of life of this group1,2,3.
In the mild stage, the disease is characterized
by symptoms such as memory loss and impaired
learning, which may be accompanied by motor
difficulties. More advanced stages may be marked by
declines in cognitive, executive and language abilities.
In relation to the disease, Câmara5 noted that 60-
80% of dementia cases are due to AD, making it the
most common chronic incurable neurodegenerative
disorder in the population worldwide4,5.
Alzheimer´s disease is a multifactorial idiopathic
disease. Disease progression is influenced by both
environmental factors (e.g. advanced age, diabetes
mellitus, stroke, obesity, smoking, sedentarism,
inadequate diet, and depression) and genetic factors
(apolipoprotein E ε4 allele)5,6.
Diagnosis of the disorder is complex and patients
often face underdiagnosis because of the difficulty
identifying initial symptoms, with diagnosis typically
being late, when cognitive impairment has become
severe. Currently, AD is recognized by a group of
clinical symptoms perceived by the patient and/or
family members, together with neuropsychological
screening tests such as the Mini-Mental state Exam
(MMSE), and complementary imaging scans such
as MRI3,7.
Physiopathologically, AD is characterized by
the aggregation of beta-amyloid (Aβ) proteins
associated with the pathological alteration in the
tau protein, where elevated levels in cerebrospinal
fluid (CSF) are explained by axonal loss. In addition,
the acetylcholine neurotransmitter (ACh) undergoes
changes in its function and is low in the brain of
AD patients, an event associated with cognitive
damage5,7,8.
Rev. Bras. Geriatr. Gerontol. 2023;26:e230012
With regard to treatment, a multidisciplinary
care plan, in conjunction with drugs treatment,
should be established, based mainly on classes of
acetylcholinesterase inhibitors (AChE) and the
N-methyl-D-aspartate (NMDA) receptor antagonist2,5.
Regarding non-pharmacological approaches, Costa et
al.9 notes that most studies involve older adults with
mild-to-moderate AD, where non-pharmacological 2 of 6
methods are typically used, e.g. physical activity or
aerobic activity, followed by cognitive intervention
or rehabilitation, music therapy and MAKS therapy
(motor stimulation, activity of daily living, cognitive
stimulation and social element).
Against this backdrop, the importance of
identifying the aspects involved in the process of
AD progression and disease screening is clear,
given the current underdiagnosis of the condition,
precluding early treatment of AD patients. Therefore,
the objective of the present study was to analyze the
clinical course of a patient with Alzheimer´s Disease
and to discuss the repercussion of early diagnosis.
METHOD
A descriptive qualitative instrumental case study
was conducted in 3 stages: 1) selection and defining
of the case; 2) data collection in the field; and 3)
organization and write-up of the case report. This
study was centered on a patient with AD, selected
irrespective of gender, who had a clinically-confirmed
(by psychiatrist) diagnosis of the condition, and
continued follow-up at the health service. Data
were drawn from the patient´s medical chart
and electronic records, containing medical notes
containing information on: a) mental health status
at presentation to the health service (Psychosocial
Care Center II); b) medication dosages prescribed
for treatment; c) signs exhibited by patient at onset
of neurodegeneration; and d) results of mental
evaluations using the MMSE.
In accordance with legal precepts, participation
of the patient entailed a visit scheduled with both
patient and spouse (legal guardian) during which
the aims of the case study were explained, together
with the rights of participants, and anonymity and
confidentiality of clinical data.
Alzheimer's dementia a case report
Data analysis entailed 3 stages: 1) pre-analytical,
consisting of reading and exhaustive examination of
the literature selected by authors; 2) exploring the
material to determine the theoretical and empirical
categories guiding the specification of the topics;
3) interpretation of the results in light of the study
objectives outlined.
Data analysis was initially focused on the patient´s
sociodemographic data, including age, place of birth
and employment background. Subsequently, the
analysis centered on clinical anamnesis of the patient,
with an emphasis not only on the patient history upon
presenting at the health service, but also on the AD
diagnosis, medications prescribed during follow-up,
as well as improvement or worsening of prognosis
based on MMSE performance. To this end, the case
was elucidated by performing an in-depth analysis of
the patient´s medical records, followed by extraction
of the pertinent information to build the case study.
After signing the Free and Informed Consent
Form, data were compiled for the case study between
July and August 2022, following approval of the
documentation by the Municipal Health Secretariat
and by the local Research Ethics Committee (permit
no. 5.616.881).
RESULTS
The study involved M.R., a 71-year-old female
patient, married, housewife, with incomplete primary
education, diagnosed with AD and hypothyroidism,
followed at the CAPS II since presenting at the service
on 10 September 2012. Screening anamnesis by
professionals at the center revealed the patient had
previously been admitted to the psychiatric ward
of the Hospital e Maternidade de Santa Cecília, in
the city of Santa Cecília, Santa Catarina state after
numerous suicide attempts. During the stay at the
clinic, the patient was placed on a treatment regimen
consisting of risperidone 1 mg 3x/day, chlorpromazine
100 mg 1x/day, diazepam 10 mg 1x/day and Puran®
T4 100 mg/day, progressing well until discharge.
Subsequently, on 4 October 2012, the patient
returned to the CAPS II for a consultation with a
neuropsychiatric professional, who prescribed the
same medication doses and, in their report, suggested
Rev. Bras. Geriatr. Gerontol. 2023;26:e230012
a possible diagnosis of schizophrenia or AD in view
of the symptoms exhibited by the patient. On 17 of
October 2012, the patient returned to the service
with anxious symptoms, for which the drug Amplictil
(chlorpromazine) 100mg 2x/day was prescribed.
The patient ceased follow-up due to problems
getting to the health service, returning in February 3 of 6
2013 for a consultation with a neuropsychiatrist, who
prescribed risperidone 1 mg 3x/day, diazepam 10 mg
2x/day, Amplictil 100 mg 2x/day and biperiden 2 mg
2x/day. On 13 March 2013, the first MMSE test was
applied, on which the participant scored 14 points,
below the cut-off for the patient´s educational level.
In September 2013, the patient was seen by
another psychiatrist and given a new prescription
of memantine 20mg 1x/day, risperidone 1mg 1x/
day, Amplictil 100mg 1x/day. On 11 June 2014, the
definitive diagnosis of AD was established. In the
medical records, the multidisciplinary team noted
that., during dance therapy sessions, the patient was
participative despite coordination problems. The
patient continued receiving psychiatric treatment,
with the disease remaining stable in 2015, and also
engaged in alternative therapies (art therapy). In
the medical records, the team reported that the
patient´s daughter had collected the medications
for treatment continuation.
In 2018, the patient (accompanied by daughter)
was seen by a different physician who conducted
an anamnesis. Based on results, the psychiatrist
documented the onset of cognitive decline 6
years prior, with the family reporting symptoms
that included selling of personal items and
furniture, irritability, visual hallucinations, hetero-
aggressiveness, failure to recognize close individuals
(except for son-in-law), decline in self-care activities,
and compromised discourse. The patient was in
a stable condition but exhibited impaired recent
memory. The prescribed therapy of memantine 10mg
1x/day, Amplictil 100mg 1x/day and risperidone 1mg
2x/day was maintained.
At a return visit on 10 October 2018, the doctor
noted stabilization of neurocognitive deficits after
use of memantine in the medical record, altering the
prescription to memantine 10mg 1x/day, risperidone
1mg 2x/day and chlorpromazine 100mg 1x/day. On
Alzheimer's dementia a case report
3 December 2018, the patient underwent another
cognitive assessment, scoring 10 points on the
MMSE. The Clinical Dementia Rating (CDR) was
also applied, yielding a score of 3 on the standard
version and 2 points on the adapted scale. On 10
February 2020, another assessment of mental state
was performed, where the patient scored 11 points
on the MMSE and 2 on the CDR. The prescribed
medication was also changed (memantine 10mg 2x/
day and donepezil 5mg 1x/day).
The patient suspended face-to-face follow-up at
the CAPS II due to the COVID-19 pandemic, but
continued taking the prescribed medications. The
patient returned in the middle of 2022 to renew the
medical prescription and again in June 2022, scoring
11 on the MMSE.
DISCUSSION
The diagnosis of Alzheimer´s Disease (AD) is
reached based on clinical analysis. Among the risk
factors, depression is most notable because it develops
with cognitive decline, as does AD, and thus may
help or hinder early diagnosis of dementia6. In the
first case, worsening depressive symptoms may
prompt seeking of mental health services, leading
to a differential early diagnosis for AD, as occurred in
the present case. In some cases, however, depression
may present as a prodrome of AD, given that the
neurodegeneration associated with dementia can
trigger depressive symptoms which, in turn, may
mimic dementia10.
Regarding AD diagnosis, 3 clinical stages are
defined: 1) mild, corresponding to the onset of
amnesia and cognitive decline; 2) moderate, worsening
of cognitive and neuropsychiatric symptoms, such as
delirium, agitation and hallucinations; and 3) severe,
patient totally dependent and overall reduction in
neurocognitive domains. Recent studies show that
the pathogenicity of AD commences long before the
onset of first symptoms. During this asymptomatic
stage, mild behavioral/cognitive alterations may
occur, although these do not characterize mild
cognitive impairment, being amenable to intervention
for slowing or preventing disease progression11.
Rev. Bras. Geriatr. Gerontol. 2023;26:e230012
With respect to the clinical assessment of the
disease, clinicians rely on tests to measure the
status of neurocognitive domains and determine
dementia progression. The MMSE is the most widely
used cognitive screening instrument owing to its
accessibility, where other health professionals can
also use this tool, and to its rapid application12.
4 of 6
In the case reported, the patient underwent
cognitive assessment using the MMSE, one of the
most applied tests for assessing cognitive function in
older people. The tool encompasses the 5 domains
of orientation, calculation/working memory, delayed
recall, immediate and episodic memory, language
and visuospatial ability13. In the case described, the
patient had 4 MMSE assessments between 2013 and
2022, yielding scores of 14, 10, 11 and 11 points.
In Brazil, Brucki et al.14 adjusted MMSE score
according to educational level, with the original
scored on a scale of 30 points. In the case study,
the patient had studied to incomplete primary level,
corresponding to 1-4 years of education on Brucki´s
classification, giving a score of 25 points. Thus, the
performance of the patient outlined earlier indicates
a deficit in cognitive function.
Pharmacological therapy is based on two pillars:
disease-modifying drugs, i.e. acetylcholinesterase
inhibitors (AChE) and N-methyl-d-aspartate
receptor (NMDA) antagonists, and anti-psychotics/
neuroleptics15. Early in the investigation, the patient
was administered risperidone and chlorpromazine
for suspected schizophrenia. At a later juncture, after
the MMSE evidenced cognitive decline, the drugs
prescription included memantine – representing the
main NMDA receptor antagonist – risperidone and
Amplictil, employed as an anti-psychotic/neuroleptic.
The patient also had difficulty recognizing close
people, exhibited compromised discourse and
impaired recent memory, suggesting cognitive
decline and justifying the use of donepezil, an
acetylcholinesterase inhibitor (AChE). This class
of drugs is recommended for patients at mild-to-
moderate stages of the disease, with the aim of
delaying cognitive dysfunction. These medications
act by inhibiting the catabolic enzyme AChE,
slowing the reduction in acetylcholine levels, thereby
improving its availability16,17.
Alzheimer's dementia a case report
This case study has some limitations. First, there
were difficulties finding eligible patients diagnosed
with AD. Second, the patient´s medical records
were lacking some information on disease course,
hindering the follow-up of AD progression. Lastly,
despite these limitations, the findings of the present
case report remain valid, with sufficient information
collected for a satisfactory investigation of the disease.
CONCLUSION
The symptoms of the patient in this case study
suggest the presence of mild-to-moderate dementia.
After use of the disease-modifying drugs, stabilization
of the condition was evident on the MMSE test.
This outcome underscores the importance of early
diagnosis and timely treatment of Alzheimer´s Disease
to stabilize the condition and promote quality of life.
However, there are barriers hampering initial clinical
analysis, particularly depression which manifests as
a prodrome for AD in some cases.
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Rev. Bras. Geriatr. Gerontol. 2023;26:e230012
AUTHOR CONTRIBUTIONS
• Luciane F. Zanotto – Administration of the
Project, Formal Analysis, Conceptualization,
Data Curation, Writing – First Draft, Writing –
Review and Editing, Investigation, Methodology,
Securing of Funding, Resources.
5 of 6
• Vanessa A. Pivatto – Administration of the
Project, Formal Analysis, Conceptualization,
Data Curation, Writing – First Draft, Writing –
Review and Editing, Investigation, Methodology,
Securing of Funding, Resources.
• Eliana R. Adami - Supervision, Validation and
Visualization.
• Ana Paula G. Pinculini - Supervision, Validation
and Visualization.
Edited by: Marquiony Marques dos Santos
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